There are a number of reasons why I chose the topic of osteoporosis for my article this month. I have written many articles on osteoporosis over the past 29 years in which tremendous changes have occurred in both the diagnosis and treatment of the disease. Today I would like to focus on the latest things you should know about osteoporosis.

When I first started in the area of osteoporosis the diagnosis was made using an extremely primitive method of bone biopsy. This was a painful, time consuming and very impractical procedure. There was very little reason to do this diagnostic procedure because other than calcium and sodium fluoride, the treatment was extremely limited with very limited benefits.

However, little did I know how an area that I had chosen to be involved in over the years would become one of the most exciting areas in the field of medicine. Today we can diagnose osteoporosis with minimal time, effort and cost. Osteoporosis is by definition characterized by low bone mass and structural deterioration of bone tissue, which leads to an increased susceptibility of fractures of all the bones in particular, the hips, spine and wrist.

The diagnostic procedure of choice is bone densitometry. This is performed in about twenty minutes and the procedure can show as little as a 1% change in bone mass over one year either for better or for worse. The procedure is now readily available in multiple locations and essentially there is no excuse for every female who has reached menopause not to have a bone density in the same fashion as they would have a mammogram or a PAP smear. There are indications to do bone densitometry on women prior to menopause, for example, if they have a history of thyroid or other hormonal imbalances, if they have had an eating disorder, or if they have a strong family history or are on long-term medications which affect the bones. Males may also benefit from a bone density because osteoporosis is not a disease limited to women alone.

Males who have similar problems to the ones I have just mentioned, including hormonal issues such as thyroid disease, chronic illness and use chronic medications for other conditions, for example, corticosteroids, may also be at high osteoporosis fracture risk.

I make a plea that everybody who has a bone densitometry should have both the hip and spine measured. The use of bone density models that simply analyze a finger or a heel is a very primitive screening process. In this day and age and certainly in areas such as Miami and Aventura, there is no reason not to get a complete bone density of the hip and spine as the time and cost are minimally, different for a more complete test result.
Furthermore, it is very important to emphasize that the interpretation of the bone density is as important as the test itself. I would strongly suggest when having a bone density test that the question as to who will be doing the interpreting of the test be asked. Unfortunately, there are many very marginal reports generated which even when bone loss is present are being interpreted as within normal limits. No bone loss should be regarded as within normal limits. One bone density by itself is also really of little benefit. It is the ability to compare the changes in bone mass from year to year, which ultimately makes the most difference in deciding therapy changes. Ideally the individual reading bone densities should be certified by one of the two national bodies in technical competency of bone densitometry.

At the moment, probably close to 28 million Americans are affected by osteoporosis. This is almost one out of every 2 women over the age of 50. By the age of 75 1/3 of all men will be affected by osteoporosis. Osteoporosis causes nearly 1.6 million fractures annually resulting in cost directly and indirectly of nearly $10 billion dollars.

In my next column I will talk about the treatment of osteoporosis, but it is very important for people who have a family history, have had early menopause, who smoke tobacco regularly, drink large amount of caffeine or carbonated beverages or have small body mass, to have a bone density as soon as possible in their adult lives to try and establish their baseline for bone mass.

The truth is that individuals suffering hip fractures have a 5 to 20% greater risk of dying within their first year following an injury than other individuals in their age group. A woman’s risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer. The point is that this can be totally prevented and ultimately osteoporosis is a disease that can be eradicated if we make an early diagnosis and aggressively treat people who have bone loss.

Author: Norman B. Gaylis, M.D., F.A.C.P., M.A.C.R.

Raynaud’s phenomenon is a result of deficient blood flow in the extremities, in particular the fingers and the toes. It is a condition named after the physician who first described it, Dr. Maurice Raynaud in France. This condition classically occurs after exposure to the cold. At times, it may be persistent and individuals suffering from Raynaud’s phenomenon may have constant discoloration of the fingers and toes associated with pain, burning sensations and numbness. Cold exposure may be as little as walking through an air conditioned room or a supermarket or may occur after holding a cold drink from the refrigerator.

While Raynaud’s phenomenon may occur in otherwise healthy individuals, it is frequently a symptom of one of the rheumatic diseases. The rheumatic diseases in particular that are associated with Raynaud’s phenomenon include: systemic lupus erythematosus, scleroderma, Sjogren’s syndrome, rheumatoid arthritis and mixed connective tissue disease.

What happens in Raynaud’s phenomenon is that the blood vessel in the fingers or toes goes into spasm, usually for a short time, resulting in deficiency of blood to these extremities. As this happens, the extremities will change colors, first turning white when they are without blood, then blue when the blood that remains in the extremities becomes deprived of oxygen and finally red, as blood flow returns to normal when the spasm relaxes. At time, only one color may be distinguished by the patient as the changes may be very subtle. The course of events may take only a few minutes or may last for many hours.

In addition to exposure to cold, emotional stress can also cause spasm of the blood vessel. The symptoms of Raynaud’s vary depending upon the severity of the disease. In most individuals, they are relatively mild and are simply uncomfortable with exposure to cold. However, in more severe instances, the symptoms can persist and one may actually get ulceration of the fingers or toes and because of the deficiency in blood supply, gangrene may even set, with the potential to lose the involved finger or toe. If you think you may be suffering from this condition, it is very important to rule out the possibility of other pre-existing illnesses as mentioned, although in the majority of people, there is no underlying cause.

There are a number of ways to manage Raynaud’s phenomenon. Obviously, the first thing to do is to avoid cold exposure and this may mean wearing gloves or socks and limiting exposure to air conditioning, cold refrigerators, etc. Raynaud’s phenomenon is far worse in the cold northern climates than it is in Florida, as we do not have the cold extremes that so often provoke this condition. Smoking is absolutely contraindicated in this condition, as cigarette smoking can further cause spasm of the blood vessels and by smoking one is, in fact, adding insult to injury. It is also very important to try to be relaxed and to try to limit emotional stress and, in fact, one of the treatments for this condition is biofeedback training, which has been shown to help relax the blood vessels by being more relaxed. Other causes of vasospasm such as migraine headache medications and certain blood pressure pills should also be avoided in this condition.

There are certain medications that are now being shown to be very helpful in this condition. The calcium channel blockers, a new group of medications, initially introduced for the treatment of angina have been helpful in reducing vasospasm. The topical use of nitroglycerin ointment may also cause some vasodilatation and counteract the spasm. Finally, if all else fails and the symptoms are persistent and ulcerations are occurring, a surgical procedure called a sympathectomy may be done with some degree of success. Overall, however, people with this condition can usually control their symptoms by avoiding emotional upsets, avoiding cold, taking care of their skin and making sure they do not have any underlying rheumatic disorder.

Author: Norman B. Gaylis, M.D., F.A.C.P., M.A.C.R.

Of the more than 25 years that I have practiced medicine as a Rheumatologist, I have been asked many times “what is a Rheumatologist?”. When I give the explanation that “he/she is a specialist in arthritis and autoimmune diseases”, the question that is often asked is “why did I choose to become a Rheumatologist out of all the specialties in Internal Medicine’?”. I can honestly say that a recent article in the Sun Sentinel on the outcome of a patient of mine with rheumatoid arthritis has answered this question very simply.

The patient, Lucille, was first seen by me when she was in her mid thirties. She was a hairdresser at that time who presented to me with multiple painful swollen joints. She was unable to work either at home or in her occupation without severe pain and discomfort and essentially her life was falling apart.

After performing the appropriate examination and blood tests, the diagnosis of rheumatoid arthritis was made. Since that time, I have treated her with multiple medications. As we have discovered and made advances in different forms of therapy over the years, we have been able to provide Lucille with progressively more function, less pain and improved quality of life.

Lucille is an artist who went from being unable to grasp a paintbrush, to producing award winning art that is being progressively recognized more and more by the art community as extremely high quality work.

From my perspective, the few paintings that are hanging up in my office that she personally painted for me, are the answer as to why I became a Rheumatologist. It has always been extremely frustrating for me to hear people state that there is no treatment that will help patients with arthritis. There is also nothing worse than seeing a patient brought into my office with crippling disease who has been misinformed and has ultimately waited far too long to seek treatment. By the time I see them, there is very little that can be done for them.

The fact is that while there are over one hundred types of arthritis, some of which can be extremely devastating, in the majority of cases, I know I can effectively help relieve my patients’ pain and symptoms dramatically. This will allow them to have a very productive life with much happiness and pleasure. There is on the one hand, nothing more gratifying than to see someone who is crippled by inflammation of their joints becoming pain-free and more functional and conversely, nothing more frustrating than seeing someone being mistreated, not treated or misinformed.

We have reached a point in the treatment of rheumatic diseases that we truly have made breakthroughs with rheumatoid arthritis and various other forms of arthritis to an extent that I would not have dreamt of when I first started practicing rheumatology.

Obviously, all forms of treatment have risks and side effects and it is my job to balance the pros and the cons and to heal my patients and not to make them worse with my treatment. I can honestly say that the majority of patients, once they have given medications a chance and learn how to adjust their behavior, lifestyle and body habits to work with their medications. usually are very receptive and responsive to treatment.

I also strongly believe that the pleasure that I see in a patient’s family and friends by the smiles that appear as their loved one’s response becomes more and more improved is another very gratifying feeling. Thus, the answer to why I became a Rheumatologist does not need to be explained when this type of reaction is recognized.

My hope is that an example like Lucille is used to make people aware that we can help everyone with arthritis, no matter what type or to what extent it has affected their life. The statement that you “don’t have to live with arthritis,” is absolutely correct and more appropriate now than ever.

I hope to continue to be able to enjoy my chosen specialty, which unfortunately is needed to help patients reduce their pain and disability. It is also something that provides me with tremendous satisfaction in being able to change their pain and disability to situations that are in fact completely different and improved.

Please, if you have any concerns about your arthritis or believe that you have some type of arthritis, seek treatment, look for a Rheumatologist and find out what is available to improve your symptoms and the quality of your life.

Author: Norman B. Gaylis, M.D., F.A.C.P., M.A.C.R.

Dr. Norman B. Gaylis

One of the most common complaints that I am asked to treat in my practice is the early retired male or female patient who has waited his/her whole life to be able to have the time and opportunity to essentially play golf or tennis seven days a week. I mention these two sports as they are probably the most common sports that retired individuals either take up for the first time or start increasing their playing time dramatically upon retirement.

While the desire, the concept and the enjoyment of being able to play golf or tennis daily as opposed to only on the weekends sounds fantastic, in fact, it probably causes more people to have shattered dreams and depression rather than actually providing the anticipated pleasure that had been expected.

Unfortunately, our bodies as they grow older are not meant to play repetitive sports on a daily basis. Furthermore, most people who have been working for most of their lives do not have the skills or mechanics to avoid problems occurring when they start utilizing their body inappropriately on a repetitive basis. In golf, the most common problems that I see are tendonitis of the elbows and fingers, and pain from pinched nerve – like symptoms occurring in the neck and the back.

I can treat the acute inflammation with a combination of anti-inflammatory medications, local anti-inflammatory steroid injections, however, these forms of treatment serve only to reduce the acute pain. It is extremely important that the player/patient understands that they should try and stretch and warm up prior to their golf game. The older one gets, the more time should be devoted to stretching. In fact, spending more time loosening up and stretching would provide more benefit to swinging a golf club on the range. Right now, most golfers go straight to the range where they touch their toes twice, swing a few clubs and go out on to the course. Further important advice includes adequate rest after having had a flare up. This could be reducing the schedule from five rounds of golf a week to two, or most importantly, allowing adequate time for the body to recover from the time of the acute inflammation to the resumption of play.

I strongly recommend for my golf patients who have problems with their hands, that they consider built up club handles which reduce the pressure across the joints and the allow the grip to be firm without being harmful. I also recommend cardiovascular activities to increase one’s stamina and muscle tone, and as mentioned, performing stretching exercises on a daily basis in particular, before a round of golf is critical.

For my tennis-playing patients, their main complaints relate to their back and knees and to a lesser extent, their neck and shoulders. The recommendations are very similar in some ways to my golf patients. They need to reduce their regular repetitive action of one game and cross train by performing other activities such as swimming or biking.

This would be extremely beneficial. The choice of a soft clay court surface is far more desirable than beating ones joints up on a hard surface as we often find here in Florida. And finally, as in golf, building up the racquet handle and performing gentle range of movement exercises for the upper body allows the player to gradually increase their stamina and ability on an ongoing basis.

In summary, having more time to play may unfortunately result in less playing time due to injuries. To get the most out of ones retirement with regards to golf and tennis, one needs to approach it in a sensible and methodical fashion. There needs to be more emphasis on choice of equipment, improving cardiovascular and muscle tone, and stretching prior to playing, than on actually playing the game itself.

I hope this article will help some people get more fun out of life and I welcome your comments one way or another.

Dr. Norman B. Gaylis

In my several years as a practicing rheumatologist, I have noticed that many people with arthritis -and sometimes, their doctors -harbor the mistaken notion that arthritis confines its symptoms to the joints alone. Certainly, the most common arthritic disorders relate to pain and swelling of the joints, but in many instances, this is just the tip of the iceberg. Extra-articular (outside the joint) manifestations of rheumatoid arthritis can, in some cases, cause extreme discomfort.

Actually, the term ‘rheumatoid arthritis’ is a misnomer. The condition should be called rheumatoid disease because of the wide range of symptoms and findings that can appear, without any apparent, direct relationship to the joints themselves. Obviously, this is because rheumatoid arthritis is not a joint disease, but is rather a generalized, inflammatory disease of the immune system, and thus can affect just about any organ system. In my view, a thorough knowledge of potential problems, no matter how rare, through consultation with a rheumatologist, will ultimately promote better health and reduced medical bills for the person with R.A.-and hopefully will not cause undue worry at every twinge or cough.

Most of the extra-articular manifestations of rheumatoid arthritis can be ascribed to either vasculitis, rheumatoid nodules, or serositis.

In vasculitis, which is an inflammation of the small blood vessels, findings may vary from skin ulceration (the

death of skin cells caused by the lack of blood flow) to inflammation of the nerve endings, which may cause weakness or abnormal sensations in the fingers and toes ranging from a pins-andneedles feeling to total numbness. In very severe cases, bleeding from the gastrointestinal tract and even stroke can result. It is important to recognize these symptoms in a very early state, because appropriate treatment can correct and very often reverse the problem.

Large rheumatoid nodules-hard clumps of tissue-are often seen on pressure points such as the elbows. While they are usually asymptomatic, though detectable, they may become painful and if the skin breaks down, or ulcerates, there rises the possibility of a secondary infection. Nodules are particularly uncomfortable when they appear over pressure points such as the buttocks.

The most serious extra-articular manifestation of R.A., however, is serositis -either pleuritis (an inflammation of the lining of the lungs) or pericarditis (an inflammation of membranes which cover the heart). The latter may result in the person having severe chest pain, fever and coughing. With the former, the clinical picture is very similar to that of pneumonia: fluid build-up, fever, coughing and, at times, the coughing up of blood.

Other manifestations of R.A. include anemia, enlargement of the lymph nodes (especially around an inflamed joint), inflammation of the eye, and, due to involvement of the joints of the larynx, hoarse voice, pain on swallowing, and shortness of breath.

Finally, in people whose rheumatoid arthritis has affected the cervical spine, neurological manifestations must he considered. Cervical spine involvement can cause severe pain in the neck and head, and weakness in the arms and legs. People with R.A. should take particular care in looking after the neck, preventing any form of trauma or whiplash injury. Many physicians advise such people to wear a cervical collar. Surgical stabilization of the spine is employed only on those rare occasions when, due to spinal cord compression, severe and definite neurological signs appear.

Fever, weakness in the extremities, chest pain-quite a catalog of symptoms. But keep in mind that such problems can also stem from everyday disorders such as a common virus, totally unrelated to your arthritis. Therefore it is very important to keep your rheumatologist informed of any change in your symptoms to help distinguish your arthritis symptoms from any other problems. For the most part, these problems are treatable, and even reversible.

Dr. Norman B. Gaylis

Scott Bridgeman has led an active lifestyle in the Miami area for the past six years. As Vocal Director for Royal Caribbean, he has supervised large cast rehearsals and choreography for review shows aboard cruise ships. The 45 year old regularly walked 4-5 miles per day until he began experiencing pain in his knees, which eventually spread to his ankles and feet. By the time he was diagnosed with Rheumatoid Arthritis (RA) thirteen months ago, he was walking with two canes and no longer able to work.

Scott’s primary physician began a course of Methotrexate, a medication commonly prescribed to reduce the pain and inflammation associated with RA. After failing to see improvement after three months, Scott was referred to Dr. Norman Gaylis, a Board Certified Rheumatologist in Aventura, Florida. Though temporarily sidelined with the effects of RA, Scott is one of the lucky ones, receiving an early referral to a rheumatologist who incorporates objective imaging in the management of this debilitating disease.

Dr. Gaylis began treating Scott with Remicade, a relatively new medication for RA given intravenously in the physician’s office, and ordered a MRI exam of his extremities. Scott recalls, “I had a previous MRI that was long, loud, and scary, so I wasn’t too excited until I saw the size of the MagneVu system. My exam was done right there in Dr. Gaylis’ office with a small MRI unit, and it was very comfortable and convenient. I met with Dr. Gaylis one week later to review the MagneVu images, and I saw for myself the bone erosions found by the radiologist. I am impressed that the physician treating me has this objective data, and I am confident about our course of treatment”. According to Dr. Gaylis, a repeat MRI will be done after six months to evaluate Scott’s response to treatment.

Scott Bridgeman has been on Remicade for seven months now, and says the difference is “like night and day”. He no longer walks with a cane, and has returned to work supervising Country, Jazz and Pop review shows for throngs of cruise vacationers. And the band plays on.

Dr. Norman B. Gaylis

This is an article that I have written many times in my life. It appears that when I look back and see what my articles reflected on the management of Rheumatoid arthritis initially twenty years ago and then more recently ten years ago. It is amazing that there was almost no change in my articles for both of those time periods. Now however, it is essentially an entirely new article.

This is because in the last years the treatment for Rheumatoid arthritis has undergone a major breakthrough. The new therapeutic discoveries have resulted in tremendous improvement for the patients suffering from Rheumatoid arthritis. The prevention of the disability and the joint damage that almost always occurred in these patients was unrealisticup until very recently. From my perspective the new treatments make it a lot more satisfying and gratifying to treat my patients with. Rheumatoid arthritis.

Rheumatoid arthritis is the second most common type of arthritis after osteoarthritis. It can affect the entire body, not only the joints. In fact it should probably be called rheumatoid disease rather than Rheumatoid arthritis. It has the potential to cause serious damage to any joint in the body and it can affect any age group. I have seen 3-month-old babies and elderly people as old as 95 years suffer from the disease.

The most, common complaint is simply pain, swelling and stiffness in the joints often with chronic fatigue. In the beginning, patients may feel that this is just simply due to over utilizing a joint. Once the condition sets in, it tends to involve more joints, be more persistent and cause more disability. This is because of the inability to perform ones basic needs at a fundamental level.

Rheumatoid arthritis is in fact, a disease of the immune system. Ironically, while the, immune system normally protects us against outside foreign bodies such as bacteria and viruses, in Rheumatoid arthritis, as in other autoimmune diseases, the immune system becomes confused. It is unable to recognize the difference between these foreign invaders and one’s own natural normal cells, and as a result, the immune system starts to attack our own natural tissues hence, the definition autoimmune disease.

Up until very recently, efforts to treat rheumatoid arthritis were at a lower level in the immune system. We obviously try to treat the pain and swelling of the joints with anti-inflammatories, corticosteroids, joint injections, which utilize cortisone-like medications, and moderate immune modulators which work to a certain extent to stop the symptoms of the disease. Medications such as methotrexate, gold and others like them certainly helped stop the symptoms of the disease but over the course of time, did not prevent progressive

damage and deformity that the disease caused.

The exciting breakthroughs, that I referred to in my first paragraph occurred approximately three years ago with the introduction of a medication known as Enbrel. Shortly thereafter, Remicade was approved for Rheumatoid arthritis and more recently a third drug, Anakinra has been introduced.

All three of these drugs, in different ways, work to not only suppress the immune system that is responsible for the pain and inflammation in rheumatoid arthritis, but also to prevent the joint damage that partially had been accepted as a normal process of the diseases progression. Studies are now showing that using these drugs not only prevent further deterioration of the joint, but in fact, reverse damage that has already occurred. From my perspective, the results of using this drugs on my patients have been dramatic. The benefit that has been provided in these patients who have previously been disabled and are now able to get out and work, play sports and perform activities that they had been unable to do for so many years is incredible.

As with any new medication, one needs to be cautious that. there are possible. side effects that we have not yet seen that we will see after long-term use. However, in the short term it would appear that the results are very dramatic. I believe any patient/individual with rheumatoid arthritis can look to the horizon with a lot more hope than ever before. Also, it is important that they be treated as soon as possible and the insurance companies should pay for these medications as soon as possible. If anybody has rheumatoid arthritis ‘and would like more information, or has rheumatoid arthritis and is not being treated with one of these new medications, I believe they should speak to their rheumatologist. They can certainly call my office to find out how to obtain one of these treatments, and if it is indeed appropriate for them or a loved one.

Dr. Norman B. Gaylis

Many people are surprised to hear that a condition, namely psoriasis, that has been historically always associated with affecting the skin only, may in fact also be one of the more common causes of arthritis. It is known as psoriatic arthritis.

This is a condition that may be seen with either the typical skin changes of psoriasis with associated pain and swelling of the joints or alternatively may in fact at times present itself with pain and swelling of the joints without the skin lesions being present. It is only after evaluating the patients fairly typical joint presentation, performing further blood tests and x-rays that the diagnosis of psoriatic arthritis is made. If the correct diagnosis is missed, the patient is given more than one diagnosis and the treatment, which in recent times has become much more beneficial and is capable of reversing the joint damage, is not utilized.

In the characteristic cases there may well be a family history of psoriasis, particularly on the male side passed from males to males. However, it is not specific to males only, as many females may also be subject to developing psoriasis and psoriatic arthritis.

The condition may occur at any age. It is often present at a very young age and usually has manifested itself by the time the patient reaches middle age. There is an association of a specific gene called HLA B27. This in particular is in the type of psoriasis that affects the spine in a similar way to ankylosing spondylitis. These patients present more commonly with neck and back pain rather than involvement of the peripheral joints.

Another form of psoriatic arthritis mimics the arthritis seen in rheumatoid arthritis and will affect primarily the joints involving the toes and the hands. Classically, these patients may develop what we call “sausage toes” as their toes swell up like small cocktail sausages and very often there will be typical nail changes in the hands and the feet which help the physician to make a diagnosis. The condition can be very painful, cause severe damage of the joints if not treated early enough and result in crippling disabilities.

The diagnosis is confirmed by typical x-ray findings. The x-rays show fairly specific abnormalities that are not necessarily seen in other forms of arthritis.

The blood tests are nonspecific which is in its own way a diagnostic feature because in conditions such as rheumatoid arthritis one will usually have positive blood tests that support the diagnosis of rheumatoid arthritis.

The joints that are involved in the hands are usually the ones closest to the nail bed, the distal interphalangeal joint as opposed to the findings in rheumatoid arthritis where you may well have more involvement of the joints further away from the nail bed. In both conditions, the distribution of the disease can be called “bilateral and symmetrical”, in other words, affecting both hands in almost a mirror image like fashion. The condition is often aggravated by stress and worsens in the presence of other co-existing diseases.

It is critical to make an early diagnosis and start conventional treatment using the so-called nonsteroidal antiinflammatory drugs. The use of these drugs still forms a basis for the reduction in pain that is required. The nonsteroidals that one would use today are the Cox-2 specific group of anti-inflammatories, which have fewer side effects than the older traditional nonsteroidal antiinflammatory drugs.

Unfortunately, these drugs do nothing to affect the course of the disease, nor do they reverse the disease. In order to do this we have used other medications. In particular, for many years we have used Methotrexate, which is a drug used for rheumatoid arthritis predominately and types of cancer. This drug in low doses does help both the skin and the joint disease in psoriatic arthritis. Careful monitoring of the patient during use of Methotrexate is needed to prevent unexpected side effects especially on the liver.

Recently, a tremendous exciting breakthrough has introduced the use of biologic anti-TNF Alpha Blocking drugs. This new group of drugs is revolutionizing the treatment of arthritis. In this category in particular, we have Enbrel, which already has been approved for psoriatic arthritis.

Remicade and Humira which are about to be approved and are currently being used in clinical research studies in our office are showing outstanding results. The use of these three drugs has allowed us to dramatically reverse both the skin changes and the joint disease. We have made many patients with psoriatic arthritis much more functional and much less symptomatic.

At this point in time I believe psoriatic arthritis is a condition that should be treated early and intensively. But it is never too late to begin therapy. We are currently conducting a clinical trial for psoriatic arthritis in our office. If you would like more information or have any questions, please don’t hesitate to call our office for an evaluation and suggestions.

Definition

Paget’s disease of bone is a chronic disorder that typically results in enlarged and deformed bones in one or more regions of the skeleton. Excessive bone breakdown and formation cause the bone to be dense but fragile. As a result, bone pain, arthritis, noticeable deformities, and fractures can occur.

Causes

The cause of Paget’s disease is unknown. Recent studies, however, have suggested that the disease may be caused by a “slow viral” infection of bone, a condition that is present for many years before symptoms appear.
In addition, there is also a hereditary factor, since the disease may appear in more than one member of a family. The hereditary factor may lead to susceptibility among family members to the suspected viral infection.

Prevalence

Paget’s disease is most common in Caucasian people of European descent, but it also occurs in African-Americans. It is rare in those of Asian descent. Paget’s disease is rarely diagnosed in people under 40 but may occur in up to 3% of the American population over 60. Both men and women are affected.

Symptoms

Bone pain is the most common symptom. The pain may occur in any bone affected by Paget’s disease and often localizes to areas adjacent to the joints (e.g., hip pain may occur when the pelvis or thigh bone is involved). Headaches and hearing loss may occur when Paget’s disease affects the skull. Pressure on nerves may also occur when the skull or spine is affected. Deformities of bone, such as an increase in head size, bowing of a limb, or curvature of the spine, may occur in advanced cases. These deformities are due to enlargement or softening of the affected bones. Although Pagetic lesions may occur in multiple sites, it does not spread from bone to bone. When it is in the hip, however, damage to the cartilage of joints adjacent to the affected bone may lead to arthritis. Pagetic bone is susceptible to fractures with even moderate stress.

Diagnosis

Bones affected with Paget’s disease have a characteristic appearance on x-rays. Sometimes, the patient’s doctor is alerted to the possibility of Paget’s disease when a blood test reveals an elevated level of alkaline phosphatase. In this case, more specific tests, such as the bone-specific alkaline phosphatase test, x-rays, and bone scans, are done. After the age of 40, siblings and children of someone with Paget’s disease may wish to have a standard alkaline phosphatase blood test every two or three years.

Hearing Loss in Paget’s Disease

When Paget’s disease affects the skull and the temporal bone (the bone that surrounds the inner ear), severe and progressive loss of hearing may occur. This may involve both sides or one side predominantly. If the loss of hearing is progressive and due to Paget’s disease, treating the underlying Paget’s disease may slow or stop the progression of the hearing loss. Hearing aids may sometimes be helpful.

Exercise

Exercise is very important in maintaining skeletal health and is recommended for some patients with Paget’s disease. Before beginning any exercise program, it is wise to discuss the program with your physician, since undue stress on affected bones should be avoided. Exercise is also helpful in avoiding weight gain that may put additional stress on the bones and in maintaining the mobility of the joints.

Medical Treatment

Two classes of drugs are approved by the FDA for the treatment of this disease. Both classes of drugs suppress the abnormal bone remodeling that is associated with Paget’s disease:

1. Bisphosphonates. Bisphosphonates are drugs that inhibit abnormal bone resorption. Three bisphosphonates are approved in the U.S. for treatment of Paget’s disease: Alendronate sodium (Fosamax®), which is given in tablet form; Etidronate disodium (Didronel®), which is also given in tablet form; and Pamidronate disodium (Aredia®), which is given intravenously.
2. Calcitonin. Calcitonin is a hormone secreted by the thyroid gland that also inhibits abnormal bone resorption. Synthetic salmon calcitonin is taken by injection; the brand names for this drug are Calcimar®, Miacalcin®, and Osteocalcin®. At this time, Cibacalein® (synthetic human calcitonin), which is another drug approved by the FDA for treating Paget’s disease, can only be obtained if a physician requests it directly from the manufacturer. Talk to your physician about the treatment that is most appropriate for you.

Surgical Treatment

There are generally three major complications of Paget’s disease for which surgery may be recommended. The first complication occurs when Pagetic bone fractures. Surgical fixation of Pagetic fractures may allow the fracture to heal in better position. The second complication occurs when the patient develops severe degenerative arthritis. If medication and physical therapy are no longer helpful, and if disability is severe, surgery may be considered as an option. Total joint replacement of the hips and knees should be reserved for the most severe cases of arthritis, when other methods of treatment are no longer effective. The third situation involves bone deformity, especially of the tibia. The surgical cutting and realignment of a Pagetic bone may help painful weight-bearing joints, especially the knees. Medical therapy prior to surgery is recommended to decrease bleeding during surgery and to prevent other complications during and after surgery.

Quality of Life

Some of the same issues that affect patients with osteoporosis and other chronic disorders affect patients with Paget’s disease. There has, however, been little research on the impact of Paget’s disease on quality of life. A study by Dr. Deborah Gold et al. that was published in the Journal of Bone and Mineral Research entitled “Paget’s Disease of Bone and Quality of Life” (vol. 11, no. 12, pp. 1897-1903) addressed the psychological,
social, and physical consequences of Paget’s disease as well as the impact they had on quality of life. This study was based on previous studies of patients with another prevalent chronic skeletal disorder — osteoporosis -because many of the physical consequences of these two disorders are similar.

Results of the study suggest that a substantial portion of the individual’s perception of quality of life depends on his or her physical condition and disease state. The greater the illness-related problems, the worse the quality of life. Income and education enhanced self-reported quality of life as did excellent self-rated health and health that had improved from 5 years previous. From this study, the researchers concluded that Paget’s disease of bone affects the psychological functioning of its sufferers considerably, and this finding may have an impact on treatment of Paget patients. If physicians and other health care professionals are aware of the likelihood of psychological issues, they may tailor treatment plans to include psychological outcomes, which may ultimately improve quality of life for patients with Paget’s disease of bone.

Specialists in Paget’s Disease

Endocrinologists (physicians that specialize in hormonal and metabolic disorders) and rheumatologists (physicians that specialize in joint and muscle disorders) are internists that are generally knowledgeable about treating Paget’s disease. Also, orthopedic surgeons, otolaryngologists (physicians that specialize in ear, nose, and throat disorders) and neurologists may be called upon to evaluate specialized symptoms in Paget’s disease.

Dr. Norman B. Gaylis

Polymyalgia rheumatica is an inflammatory disorder of the muscles characterized by pain and stiffness in the shoulders, neck, arms, lower back and legs. It occurs mainly in people over the age of 50 and is more common in woman than in men. Many people, when developing the symptoms initially believe that their aches and pains are simply due to a flu-like illness or possibly getting older. Unfortunately, this leads to a somewhat simple diagnosis being left untreated in many people for far longer than is necessary. It is because the symptoms are so nonspecific that the diagnosis is often times missed.

As the condition progresses, the pain including the stiffness may increase to the point where the sufferer cannot lift his/her arms or get out of a chair without great pain; evening turning over in bed or getting off the toilet seat may be very difficult and painful. At times, this condition may be associated with fatigue, depression, sweats and a total feeling of debilitation.

It is unfortunate that many times this diagnosis takes awhile to be made as it is a very simple illness that can be treated once other problems have been ruled out. A person having the symptoms I have just described should have a thorough examination to exclude other causes of muscle pain, fatigue and weakness. In particular, one should rule out more serious conditions such as malignant disorders, other arthritis disorders and an autoimmune inflammation of the muscles called polymyositis. In addition to a thorough physical exam, blood tests and x-rays may be needed to help make a diagnosis but the most pertinent blood test that helps clench the diagnosis is an abnormally elevated sedimentation rate.

The medicine used for the treatment of polymyalgia rheumatica is exclusively and specifically prednisone. This medicine is a cortisone derivative and significantly reduces inflammation in the muscles. It is the one and only drug used to treat polymyalgia rheumatica and, while there are obviously side effects-to prednisone, the therapeutic benefit that it provides compared to other treatments, makes the choice easy. The response to prednisone is dramatic and diagnostic in and of itself.

The role of the rheumatologist is to find a balance between the effects of the disease versus the potential side effects of the medication. This is done watching the course of the disease by periodically testing the blood sedimentation rate and maintaining the lowest possible dose of prednisone. The ultimate objective is to wean the patient off the medication when the disease goes into remission which usually happens 6 months to 2 years after the initial onset of symptoms.

In a small number of patients, an associated condition causing inflammation of the blood vessels on the side of the head, namely the temporal artery, can occur. This is a disease known as temporal arteritis which needs to be recognized as it can lead to blindness.

If you think you have symptoms that could be caused by polymyalgia rheumatica, please speak to your physician as this is a very treatable condition and there is no reason for patients to suffer unnecessarily from the debilitating pains and functional loss of polymyalgia rheumatica.